The Many Reasons to Discuss Sex with Patients

As pelvic rehab providers, we may find it easy to talk to our patients about sexual function when it is a patient who comes to us with a sexually relevant problem or directly related diagnosis, such as dyspareunia or limited intercourse participation due to prolapse symptoms. However, are we talking to our other patients about sexual function? Are they talking to us about it? What about our orthopedic patients - are we routinely asking them about how their problem can affect their sexual function? Some recent studies found that 32% of patients planning to undergo a Total Hip Replacement (THR) had reported concerns about difficulties with sexual activity^{Baldursson, Wright}. Was the fact that they could not participate in sexual activity due to the hip pain a driving factor when considering the hip replacement, maybe? Just because a patient doesn’t ask, does not mean that they don’t want to know how their orthopedic injury affects sexual function. Resuming sexual function is an important quality of life goal that is included on few outcome assessment forms, however, there are some that address this subject such as the Oswestry Disability Index for Low Back Pain. Discussion of this topic should be addressed more routinely than it is.

A good example of an orthopedic patient who may appreciate the discussion of their injury and sexual function may be a patient undergoing a total joint replacement. A patient who undergoes a total hip replacement (THR) likely has movement precautions for a set amount of time and we should educate these patients about when to resume sexual activity and what positions may be more comfortable and safe for them with their new hip. It would be terrible for a patient to suffer a hip dislocation or implant failure during sexual activity because they returned to sexual activity prematurely or did not think about their movement precautions. Our patients are thinking about it, but sometimes may be too embarrassed to bring it up. So as a physical therapist, bringing it up in a professional way can help ease the awkwardness your patient may be feeling about the topic. As physical therapists we generally have more time with the patient than the surgeon and this can help create a comfortable space to discuss these topics.

It is important to remember that just because a patient is not in our office for a directly related sexual problem, it is still important to at least open up the dialogue about sexual health. One study in 2013 had patients complete a questionnaire on their sexual function after undergoing a total hip or total knee replacement and 90% reported improved overall sexual function^{Rathod, et al.}. We should try to make the conversation part of our routinely delivered information for a total joint replacement, for example when telling our THR patient, you can resume driving at 3-6 weeks (or when cleared by surgeon), you have Range of Motion precautions of avoiding internal rotation, hip flexion past 90 degrees, and hip adduction (crossing the legs) for the length specified by your surgeon (if it was a posterior approach THR), and you can resume sexual function at 3-6 weeks (or when cleared by the surgeon), or when you feel ready after that. It is important to give the patient some kind of guideline about when they can expect to resume sexual activity, however, always emphasize that it should be resumed when the patient is ready so they don’t feel pressured before they are ready. Also as pelvic rehab practitioners we can offer them guidance about what positions may be best for them when returning to sexual activity to put less strain on the prosthesis and hip as well as help them be comfortable. To continue with our example for THR (posterior approach) their precautions are likely to restrict hip flexion past 90 degrees, hip internal rotation, and adduction, so for a man or woman following THR lying on their back would be a safe position.

As physical therapists it is our job to provide guidance. Instead of telling people what not to do, helping them find a safe way to do things they want to do to maintain function should always be our goal. Sexual activity participation is definitely an important function for quality of life that is often overlooked and not discussed, so talk to your patient about it, they will likely appreciate it.

One useful tool to learn more about positioning for sexual activity is the Herman & Wallace product “Orthopedic Considerations for Sexual Activity.” It provides a great list of positions with pros and cons of each position, and is a helpful visual aid for your patients to help them return to sexual function safely with consideration of their respective injuries.

Baldursson, H., & Brattström, H. (1979). Sexual difficulties and total hip replacement in rheumatoid arthritis. Scandinavian journal of rheumatology, 8(4), 214-216.
Wright, J. G., Rudicel, S. A. L. L. Y., & Feinstein, A. R. (1994). Ask patients what they want. Evaluation of individual complaints before total hip replacement. Journal of Bone & Joint Surgery, British Volume, 76(2), 229-234.
Rathod PA, Deshmuka AJ, Ranawat AS, Rodriguez JA. Sexual function improves significantly following total hip and knee arthroplasty: a prospective study. Program and abstracts of the 2013 meeting of the American Academy of Orthopedic Surgeons; March 19-23, 2013; Chicago, Illinois. Poster P023.